john nessa - semiology

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  • JOHN NESSAA B O U T SIGNS A N D S Y M P T O M S : C A N S E M I O T I C S E X P A N D T H E VIEW OF CLINICAL MEDICINE?ABSTRACT. Semiotics, the theory of sign and meaning, may help physicians complementthe project of interpreting signs and symptoms into diagnoses. A sign stands for something.We communicate indirectly through signs, and make sense of our world by interpretingsigns into meaning. Thus, through association and inference, we transform flowers into love,Othello into jealousy, and chest pain into heart attack. Medical semiotics is part of generalsemiotics, which means the study of life of signs within society. With special referenceto a case story, elements from general semiotics, together with two theoreticians of equalimportance, the Swiss linguist Ferdinand de Saussure and the American logician CharlesSanders Peirce, are presented. Two different modes of understanding clinical medicine arecontrasted to illustrate tile external link between what we believe or suggest, on the onehand, and the external reality on the other hand.KEY WORDS: The theory of signs, symptoms and signs, diagnostic interpretation,structural linguistics, Ferdinand de Saussure, Charles Sanders Peirce, medical semiotics,scientific mode of understanding, henneneutic mode of understanding 1. I N T R O D U C T I O NEven though the expression "signs and s y m p t o m s " tends to c o m e out in asingle breath, as a unit, the two concepts are often discussed seperately inthe medical literature. According to Lester King,1 s y m p t o m s are subjective,or intersubjective, verbally expressed sensations, presented in the medicalconsultation. A sign is more objective. It unravels a disease when perceivedand interpreted by a skilled clinician. A clinical symptom is, unlike a sign,transient and volatile, without substantial information. T h e distinction between signs and symptoms is one o f the consequenceso f biomedicine having b e c o m e part o f the natural sciences during the lastcentury. In the Hippocratic tradition, a symptom had its own status, givinginformation for medical observations. A s y m p t o m was three-dimentional,in the sense o f pointing to the past (anamnesis), present (diagnosis) andfuture (prognosis). 2 The Galenic tradition, which was the only authoritativemedicine o f the Middle Ages, embodied theoretical medical knowledge intexts called Institutes o f Medicine. 3 S e m i o l o g y (from G r e e k s e m a - s i g n )was one o f the five segments o f these texts.Theoretical Medicine 17: 363-377, 1996.(~) 1996 Ktuwer Academic Publishers. Printed in the Netherlands.
  • 364 JOHN NESSA Sign Interpretation Reference (into meaning) (to an object) Figure 1. Different aspects of the message. A medical consultation often starts with the patient presenting a symp-tom, a bodily sensation of some kind. The common assumption is that thesymptom may express bodily or emotional pathology. A healthy person hasno symptom. The problem is, however, that even in patients presenting withone or more symptoms we often cannot identify any significant pathology;we have no physical findings, all tests are normal .4 The patient neverthelessusually wants an explanation for his or her sufferings, which biomedicinein many cases cannot give. And traditional explanations, such as somati-zation, hypochondriacal symptoms or functional overlay, are insufficient,pejorative and theoretically inadequate for both doctor and patient. 5 2. SEMIOTICSThe word "semeion" stems from the Greek noun "sema", which means"sign, signal, mark, token". The term "semiotics" is understood as thetheory of sign and meaning, and has been given various definitions. Iuse the Saussurian term "the study of life of signs within society". 6 Thesubject matter of semiotics is messages, any messages whatsoever, andtheir relation to interpretation, meaning and reference (Figure 1). Meaningand reference are not identical terms. The meaning of a message is givenby what the receiver understands by the message, literally how the messageis interpreted. The reference of a message concerns the relation betweenthe message and the object in the world the message is referring to. Thedifference between the terms may be illustrated by a clinical example:A patient complains of abdominal pain. The surgeon, interpreting it asappendicitis, decides on an operation. The peroperative finding is a paleappendix and enlarged nodes. Hence, the meaning of the sign "abdominal
  • SEMIOTICS AND CLINICAL MEDICINE 365pain" for the surgeon becomes "a suspected appendicitis". But its reference,namely the source, the object of the pain, is unknown, or perhaps, a viralinfection giving enlarged lymph nodes and abdominal pain. Semiotics contains theories and models about linguistic signs (words)as well as gestures and other signals which are perceived and interpretedas part of the interaction between man and the world around him. In this article, my aim is to show if and how the theory of semioticscan be used to expand the view of clinical medicine. Theories of signswill be used as key concepts for understanding medical symptoms andtheir pragmatic and clinical function. Special emphasis will be put on theSwiss linguist Ferdinand de Saussure and the American logician CharlesSanders Peirce, two theoreticans of equal importance to the developmentof modern semiotics. A clinical vignette will be used as a heuristic device,to illustrate the relevance of semiotics to clinical medicine. 3. CASE HISTORYA case history presented by Cecil G. Helman may be well known to manyphysicians: A man in his forties consulted his general practitioner duringa busy practice day for two episodes of pain on the left side of his chest. 7He was afraid that the pain had "something to do with my heart". Hewas a busy man, and admitted to his doctor that he had been "under a lotof stress recently". He was briefly examined by the general practitioner,who found no physical abnormality, concluding "its just due to strain, butwed better be sure and run a few tests". He was sent to a hospital, toldby a doctor there that he had had a small heart attack, "probably anginalin origin". The patient asked for a second opinion by a cardiologist, whofound no abnormalities whatsoever, and told the patient that his "tension"in his daily life was responsible for his "hyperventilation". 4. LANGUAGE AS SEMIOTICS: FERDINAND DE SAUSSUREFerdinand de Saussure (1857-1913) was a Swiss professor in linguistics.His theories, also called structural linguistics and semiology, in addition tothe widely accepted term semiotics, is primarily a theory about language.Essential in his theory is the term linguistic sign. A sign is, according toSaussure, a dual entity. 8 It consists of both a noise and an idea, a soundthat signifies (= signifier) and a concept that corresponds to it (= signified)."Signifier" and "thing signified" are inseparable, as are the two sides ofa coin or the inside and the outside of a circle. To have a sign that not
  • 366 JOHN NESSAsignifies anything is like having a coin with one side only. The meaningof a sign is a concept to be interpreted according to an idea, not a thingidentified as an object (Figure 1).9 The relation between "signifier" and"thing signified" is arbitrary and conventional. Therefore the same ideacan be called "stomach" in English and "Magen" in German.~ Both medical symptoms and medical diagnoses are conceptualizationsof ideas, and hence linguistic signs. And so are the words "strain", "angina"and "hyperventilation", the three different labelling diagnoses taken fromthe case story. These words, as noise or as written signs, are in themselveswithout meaning. They get their meaning in relation to an idea, a conceptabout diseases. Hence, they convey a message about everyday life (strain),cardiology (angina) and psychodynamics (hyperventilation), respectively.The signs also refer to a physical object outside language, to the physicalworld which the patient is part of. Maybe we could find later on, byan angiographic examination, abnormalities (partly or fully) responsiblefor his pain. Then we would find that the sign "chest pain" refers toan identifiable extra-mental physical entity, an object in the world. Butthe meaning of the sign, the "thing signified," is, according to Saussure,independent of this. He regards language as a system independent of thephysical, extra-linguistic reality. 11 Language is not primarily a naming-process of objects in the world. This does not mean that Saussure deniesthe possibility of a connection between language and reality. But accordingto his notion of a sign as a pure linguistic entity, he prefers to emphasizethe social and intersubjective character of all discourse. ~2 Language is"a system of interdependent terms in which the value of each term resultssolely from the simultaneous presence of the others". 13Words and conceptsare constituted as signs by their simultaneous differences from other signs.A sign both tells what a concept is and what it isnt. By saying "strain","angina" or any other medical diagnosis, the words act as signs by theirsimultaneous differences from other signs: It is "strain" that is implied,"not angina". 5. LOGIC AS SEMIOTICS: CHARLES SANDERS PEIRCEIn addition to structural linguistics, semantic theory was developed mainlyby Charles Sanders Peirce (1839-1914). Peirce defined a sign as "somethingwhich stands to somebody for something in some resp